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1 Türk Aile Hek Derg 2012;16(4): TAHUD 2012 Durum Raporu Position Paper doi: /tahd Family Medicine s academic contributions Family Medicine Research Days, zmir, Turkey Aile Hekimli inin akademik katk s Aile Hekimli i Araflt rma Günleri, zmir, Türkiye Tom Freeman 1 Summary Özet Durum Raporu In this paper which is mainly based on my speech in the Family Medicine Research Days, zmir, Turkey, in November, 2012, I have tried to place family medicine in the wider landscape of academic medicine and provide some sense of how it has grown in its own right as an academic discipline with unique contributions to provide. In order to understand the unique contributions of Family Medicine, I have first explained two concepts that will help to build a framework to understand where we fit into the larger academy of medicine. Following that I have presented some further details of the specific contributions of academic Family Medicine and concluded with what I see as some key challenges ahead. As an academic discipline, it has established a firm foundation over the past 40 years. Key words: Family practice, holistic medicine, research priorities. Esas olarak Kas m 2012'de zmir, Türkiye'de gerçeklefltirilen Aile Hekimli i Araflt rma Günleri'nde yapt m konuflmam n yer ald bu yaz da, aile hekimli inin genel akademik t p içindeki yerini saptamaya ve sa lad akademik katk lar ile özünde akademik bir disiplin olarak nas l geliflti i hakk nda bir parça bilinç oluflturmaya çal flt m. Aile hekimli inin kendine özgü katk s n anlayabilmek amac ile önce genel akademik t p içinde nerede yer ald m z anlamam z yolunda bir çerçeve oluflturacak iki temel kavram aç klad m. Bunun ard ndan aile hekimli inin özgün akademik katk lar n n ayr nt lar n sundum ve bizi bekledi ini düflündü üm baz zorluklardan söz ettim. Aile hekimli i, akademik bir disiplin olarak, geride b rakt m z 40 y lda sa lam temeller infla etmifltir. Anahtar sözcükler: Aile hekimli i, bütüncül t p, araflt rma öncelikleri. I begin by expressing my thanks to the organizers of this conference, and particularly Dr. Guldal, for inviting me to address this assembly. I look forward to learning more about Family Medicine here in Turkey and enjoying your wonderful country. It is thrilling to be so close to Pergamon, the home of Galen, perhaps the greatest of Hippocratic physicians of antiquity. I bring you greetings from my home Department of Family Medicine at Western University in London, Ontario, Canada. I take as my point of departure or beginning, the recognition that family medicine, as an academic discipline has existed for almost 50 years in some countries. It is appropriate to ask then, how successful has it been in establishing an academic or research base? What has family medicine contributed to academic medicine in general? The organization of this talk will be as follows: Two major views of human illness How paradigms change How academic family medicine began The evolution of the academic base of family medicine Challenges to academic family medicine In order to understand the unique contributions of Family Medicine, I am going to present to you two concepts that will help to build a framework to understand where we fit into the larger academy of medicine. Following that I will present some further details of the specific contributions of academic FM and conclude with what I see as some key challenges ahead. The first landmark concept is that it is important to distinguish between two great world views or cosmologies in medicine that have their roots in antiquity. I recognize that there is a danger of oversimplification. Keeping that warning in mind however, bear with me. On the one hand we have what is known as the Hippocratic or physiological or environmentalist view of 1) Family Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada 181

2 Durum Raporu human illness and disease that holds that illnesses arise out of an imbalance between the organism and its environment; they occur when the organism s ability to adapt to the changing environmental pressures are exceeded and, as the organism tries to adjust, symptoms arise and physiological and psychological systems try to compensate. Our ability to adapt is linked of course to our genetic make-up, nutrition, psychological make-up, social supports and so forth. We can remain in balance for greater or lesser periods of time depending on the challenges in our physical and psychological environment, but as Renee Dubos argues, health is a mirage. This idea is one that can be extended to include the social environment as well which can act to aid our adaptation or tip it over the edge into illness. An example that I often see in my clinical practice is the elderly couple who together have learned to compensate for each other s disabilities. Perhaps one partner has declining physical health but remains cognitively intact and the other is showing signs of cognitive decline but continued physical health. Together the couple is in balance within a limited scope, but we all know that eventually something will occur to throw it out of balance. Sometimes it can be a very minor event, but it proves just enough to exceed the ability of the couple to adapt and it is no longer possible for them to remain in their own home and they must seek another more supportive living environment. In the environmental or Hippocratic approach, the goal of treatment is to restore balance in the physical, psychological and social areas. Treatment takes the form of a regimen and is modified as the course of the illness progresses. This approach is captured nicely in this quotation from Hippocrates advising physicians entering a new city: to consider its situation, how it lies as to the winds and the rising of the sun whether it is naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which he inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor and not given to excess in eating and drinking. [1] On the other hand is what is called the biomedical or structuralist view point which sees disease or illness as something from outside the organism that is inflicted upon it resulting in a change in its structure or function. Diseases are independent entities in nature. In the standard clinical method, we seek to categorize patients with a disease label. This point of view is reflected often in our language in medicine when we speak of diseases as if they have an existence of their own as if they could somehow exist separately from the person they afflict. We call this reification of disease and it has a number of consequences Table 1. Differences between the Hippocratic and Biomedical schools of thought* Hippocratic Organisms and illnesses Individual description Concrete High-context Holistic Regimen Prognosis Biomedical Organs and diseases Classification Abstract Low-context Reductive Specific remedy Diagnosis *Adapted from Textbook of Family Medicine. 3rd ed, McWhinney IR, Freeman T, to our approach to therapeutics. We talk about managing diseases as if they are something that can be manipulated. We seek a specific medicine or surgery to remove the disease and cure the patient. For the remainder of this presentation I am going to refer to this point of view as biomedicine since that is the name by which it has become known in our time (Table 1). It is, of course, an oversimplification to say that these world views are completely distinct and separable in the real world. In the real clinical world we use both of them at different times. It is true, however, that at any given historical time, one of these cosmologies is the dominant one and the other takes a back seat. The Hippocratic one was the dominant one, in fact, for most of recorded history. You will recognize it in such phrases as starve a cold; feed a fever and in the longstanding tradition of bloodletting to reduce bodily heat. The ancient practice of altering one s diet to balance the four humors is part of this tradition. The environmentalistadaptive or Hippocratic approach re-emerged in the 20th century in the field of public health and health promotion. It wasn t until well after the scientific revolution of the 17th century that it was challenged and indeed, in North America it was not until the early 20th century with the reforms led by Abraham Flexner [2] and William Osler [3] that things began to tilt toward the biomedical approach. This latter approach has been greatly strengthened by the successes of science and the emergence of new technologies and was the undisputed dominant world view of medicine in the 20th century. So, the first concept is the two world views in medicine. The second concept on which to build a framework is Thomas Kuhn s idea around paradigms and paradigm changes. Now I will not go into his important writings in great detail, but wish to point out that his book The Structure of Scientific Revolutions, [4] published in 1962 is recognized as one of the most influential books on the history of science ever written. It goes without saying 182 Freeman T Family Medicine s academic contributions

3 that the very word paradigm, though not originating with Kuhn, became a common part of our language after the publication of this book. In the Kuhnian sense, a paradigm in science defines what is to be observed, the kinds of questions that are supposed to be asked, how these questions are to be structured and finally, how the results of scientific investigations should be interpreted. In the absence of a paradigm, all observations are equally important and it is impossible to move forward or to even define direction. Once a dominant paradigm is established it is possible for scientists to engage in what he called normal science in which it is possible to make progress to a greater understanding of that portion of the universe in which the scientist is engaged. One of the paradoxes of well defined paradigms is that anomalies occur and, over time, accumulate. Anomalies are occurrences that don t fit or can t be explained within the paradigm. I m sure you can think of many clinical issues that you ve faced that don t fit into the dominant paradigm of biomedicine and I will come back to some of them later. There are a number of possible responses to anomalies: a) they can be ignored completely; b) they can be incorporated into a suitably revised paradigm. This may take some time and involve technological or methodological innovations. This in fact, helps justify ignoring them to begin with, with the expectation that they can be dealt with later. However, over time anomalies become difficult to avoid and there occurs greater dissatisfaction with the prevailing paradigm. As this occurs, it is common to see the practitioners in a field return to consideration of the basic assumptions inherent in their paradigm and there occurs a literature that is more philosophical in nature. Other signs of impending paradigm change are the proliferation of competing paradigms that, to a greater or lesser extent, attempt to explain the anomalies. There can be a long period of change during which things take on the appearances similar to the preparadigm stage with no clear consensus about how to proceed. Eventually a new paradigm takes hold, usually introduced by someone completely new to the field or from outside the field altogether. There occurs a complete shift to the new paradigm that almost overnight becomes the dominant world view for that field and which will define a new period of normal science, this time with questions and methods defined in a completely new way. Now let s combine these two concepts, the idea of Kuhnian revolutions and that of the two contrasting cosmologies of medicine to see where family medicine fits. As I mentioned, in North America the medical reforms of Flexner and the tremendously influential work of William Osler launched an era in which the biomedical view has dominated the medical landscape. It is important to recognize that one of the reasons for the great success of biomedicine was that it proved to be dramatically effective against infectious diseases which dominated the medical landscape of that time. The truly remarkable advances in technology and pharmacology have revolutionized medical care. Like all revolutions it incited great enthusiasm. George Engel, the founder of the biopsychosocial framework in the 1960 s was quoted as saying: the basic premise of today s scientific medicine is that the book of man [sic] is written in the language of the biological sciences, ultimately molecular genetics and biochemistry. [5] The Center for Molecular and Genetic Medicine at Stanford is quoted as saying: the new medicine is based on the present belief that almost all human diseases are, in some way, genetically determined, and that given precise understanding of structure, organization and the regulatory processes of genes many diseases can be prevented or cured. [5] Despite the enormous successes of biomedicine, and just as described by Kuhn, anomalies within the biomedical model began to accumulate. Problems that biomedicine could not explain or deal with arose. For example, inherent in the conceptual and organizational structure of biomedicine and consistent with Western philosophy since Descartes is the separation of the mind and the body. Given the foregoing statements it is clear that biomedicine deals principally with the body. The mind is left to, what is at times a peripheral branch of medicine called psychiatry. Despite this, as long ago as 1983 it was possible to cite over 1300 studies showing the influence of mental/emotional states on pathogenic changes. These represented a direct refutation of the separation of mind and body and were glaring examples of anomalies to the dominant biomedicine paradigm. The placebo response is another major anomaly and a good example of one way in which a paradigm can deal with phenomena that don t fit. It has not proved possible to explain the placebo response within the biomedical paradigm, so it is set aside and controlled for in experiments. Direct studies to deepen our understanding of this have been late in getting started and not well funded. The placebo effect varies between 10 and 90%. [6] We now know that the placebo response is not only found in subjective responses such as anxiety and pain, but also in measurable physiological processes. In a powerful recent example of this, patients with end stage coronary disease were randomly assigned to receive angiogenesis and laser myocardial revascularization therapy or placebo without laser. Those in the placebo arm showed improvement in mean angina class, exercise treadmill time and quality of life and these improvements were maintained at the two year follow-up. [7] Durum Raporu Türkiye Aile Hekimli i Dergisi Turkish Journal of Family Practice Cilt 16 Say

4 Durum Raporu Further, recent evidence indicates that most of the newer antidepressants are barely better than placebo. [8] It is indeed an anomaly of biomedicine that we don t spend as much time and effort learning to understand and perfect the placebo response, but, rather treat it as something to be controlled. Family practice has perhaps been more likely to see the flaws in the biomedical paradigm because we see patients in the early stages of illness and our commitment is ongoing. Once a specialist has dealt with that portion of a patient s problem within his/her expertise, they are finished with them and no longer see them on their list of patients. For family physicians, we continue to care for those patients with conditions such as fibromyalgia and chronic fatigue syndrome and myriad other ailments for which the biomedical model offers no relief. As described by Kuhn we see that as questions and anomalies arose and the limitations of biomedicine became more apparent, there occurred an increase in the literature around philosophy and ethics. Recall that Kuhn said that as anomalies arise and people begin to question the dominant paradigm, there is tendency to look at the fundamental assumptions and beliefs of the paradigm. Beginning with 3 journals in the 1970s and expanding by 3 more journals in the 1980s, 5 more in the 1990s and 3 in the 2000 s, journals devoted to philosophy and ethics in medicine and health care began to be published. This is evidence that there was a turning inward by medicine and a questioning of basic assumptions (Table 2). Not only did the profession begin to reconsider its basic assumptions, the public, frustrated with some of the shortcomings of mainstream medicine, increasingly turned to what has become known as alternative medicine. This has been a phenomenon found in both developing and developed countries. In the U.S. a national survey found that 1/3 of respondents had used at least one unconventional or alternative therapy over a 12 month period. [9] It shouldn t be supposed however, that mainstream biomedicine was ready to yield to or even acknowledge these controversies. In a 1985 editorial, the NEJM wrote: It is time to acknowledge that our belief in disease as a direct reflection of mental state is largely folklore. In general, biomedicine proceeded as if there were no such controversy. [5] In the midst of these symptoms of increasing questioning and recognition of the shortcomings of biomedicine, a new discipline in medicine arose, born in part in response to societal pressures for more accessible and personal care. I will not get into here whether family Table 2. Journals of medicine, philosophy and ethics and their initial year of publication Journal of Medical Ethics 1975 Journal of Medicine and Philosophy 1976 Studies in Philosophy of Medicine 1977 Theoretical Medicine 1983 Journal of Medical Humanities 1989 HEC Forum (Healthcare Ethics) 1989 Kennedy Institute of Medical Ethics 1991 Cambridge Quarterly of Healthcare ethics 1992 Journal of Law and Medical Ethics 1993 Medicine, Healthcare and Philosophy 1998 Theoretical Medicine and Bioethics 1998 BMC Medical Ethics 2000 American Journal of Bioethics 2001 Philosophy, Ethics Humanities In Medicine 2006 medicine represented a rebirth of an old discipline called general practice or was something new altogether. The name itself signaled a departure as it reflected the influence of the social sciences on medical thinking and emphasized the importance of context, including the family, on health and illness. In Canada, departments of family medicine began to be established in medical schools beginning with Western University, McMaster and Calgary in 1968 and by 1976 there were 16 such departments across the country. One of the most prolific and celebrated thinkers in family medicine, Dr. Ian McWhinney arrived in Canada to become the first Chair in Family Medicine in Canada. His numerous publications have become the mainstay of many academic departments of family medicine around the world and were essential to the founding of family medicine as an academic discipline.with the background that I ve described, let s look at what academic family medicine has contributed to academic medicine in general. To begin: McWhinney identified 4 characteristics of any discipline (Table 3). [10] Table 3. Four characteristics of any discipline identified by McWhinney 1. Unique field of action 2. A defined body of knowledge 3. An active area of research 4. A training which is intellectually rigorous 184 Freeman T Family Medicine s academic contributions

5 Our field of action is in the community and it is partly because of the proximity of our practices to where our patients live and work that family medicine saw the importance of context to diagnosis and therapeutics. The relevance of the social sciences to medicine and the incorporation of some of the thinking there was one of the unique characteristics of family medicine in its early years. Our relationship with patients is unique as our commitment to them is often prior to any medical problems; it is comprehensive in scope and longitudinal in time. It is this relationship that lies at the root of what makes family medicine unique. Other disciplines in medicine are defined by their focus on systems (e.g. cardiology, endocrinology), particular therapeutic approaches (e.g. surgery). Only family medicine defines itself by the physician s relationship to the patient. A survey carried out by the Centre for Studies in Family Medicine in 2004, of family physicians and specialists in our region asked questions about the reasons these practitioners chose to live in their present practice community and, also, what kept them there. The commonest reason for FPs to locate in a particular community varied depending on whether they were in rural communities, larger urban sites or in a city with an Academic Health Science Center. Prominent among the reasons were closeness to family, growing up in the area and, finally, opportunities for a full range of practice. In contrast, for specialists, the most common reasons for locating their practices where they did were opportunities for full range of practice, the presence of supportive and skilled medical colleagues and workload. When asked what kept them in the community in which they practiced and here is the key point, family physicians most commonly identified their relationship with patients as the reason, whereas specialists identified most commonly the relationship with colleagues. The picture that emerges here confirms the commitment of FPs to their patients, but one cannot get around the impression that these FPs were, by their upbringing and the high value placed on family, a different kind of practitioner than specialists. By their personal history and natural inclination, they are more embedded in their community. Turning now to the second and third items in McWhinney s characteristics of a discipline, how well has FM done in articulating a defined body of knowledge and active area of research? Consistent with the needs of an academic discipline, FM has developed its own literature that has helped to define its knowledge base. Such literature, whether consisting of peer reviewed papers or textbooks involves both a discussion internal to the discipline and elements of an external discussion with others in the larger field of medicine. For this section of this presentation, I want to acknowledge and thank Lynn Dunikowski of the College of Family Physicians Library for her invaluable assistance and support in developing this information. What I shall present is a pilot study that we are in midst of expanding upon. Beginning as early as 1955 there arose a small number of journals devoted to family medicine coinciding with the founding of colleges of family practice. There then occurred a steady increase in the 1970s as academic departments became more established. There have been a total of 22 English language journals devoted specifically to family medicine with 19 remaining in publication (Figures 1 and 2). There are many other family medicine journals, in languages other than English, such as here in Durum Raporu Figure 1. Number of family medicine journals by year. Türkiye Aile Hekimli i Dergisi Turkish Journal of Family Practice Cilt 16 Say

6 Durum Raporu Figure 2. Family medicine journals publication timeline. Turkey. The impact factor of these journals varies between 0.5 and 4.5. These scores are in the range of impact factor scores of all general medical journals, shown on Figure 3 by the heavy red line. Textbooks typically help to define a field of activity and given that they tend to be a distillation or summary of knowledge it is to be expected that there would be a time lag in the increase in number of textbooks when compared to published literature and this is apparent for textbooks in family medicine/family practice/primary care (Figure 4). Let s examine a little of what the literature in family medicine tells us about what has preoccupied the discipline. In a review of the family medicine literature between 1980 and 1985, Culpepper and Becker [11] reported roughly 4 areas of research interest. These were the early days of FM research. Themes of family medicine research, were: 1. The care of families and their problems 2. Theoretical frameworks in family health 3. Methods work to study families and their effects on health 4. Original research in family and health These are quite appropriate and understandable topics for a new discipline in the midst of defining itself. To look at what currently occupies our interests in research and scholarship we examined the top 12 English language journals in family medicine and the 5 most frequently cited articles in each of them over the decade I then categorized these papers using a card sort method and derived the following themes. So, just to be clear, these represent the dominant themes in family medicine journals as measured by the number of times that articles were cited. Themes of family medicine research, were: 1. Clinical issues: by far the greatest number of commonly cited papers in FM literature fall into this category. They can be subdivided into the following: 186 Freeman T Family Medicine s academic contributions

8 Durum Raporu or dependence in a general practice population. Aertgeerts B et al 2001 Br J Gen Pract 51 (464): , cited 86 times) 2. Epidemiology in family practice (e.g. The community prevalence of chronic pelvic pain in women and associated illness behavior. Zondervan KT et al 2001 Br J Gen Pract 51(468):541-47, cited 76 times) 3. Patient experiences (e.g. Barriers to help seeking in people with urinary symptoms. Shaw C et al 2001 Family Practice 18(1):48-52, cited 87 times) 4. Research methods (e.g. Understanding interobserver agreement: The kappa statistic. Viera AJ, Garrett JM 2005 Family Medicine 37(5):360-63, cited 162 times) 5. Physician issues (e.g. Influences on GPs decision to prescribe new drugs - The importance of who says what. Prosser H et al 2003 Family Practice 20(1):61-8, cited 103 times) 6. Conceptual (e.g. Mind-body medicine: State of the science, implications for practice. Astin JA et al 2003 J Am B Fam Pract 16 (2):131-47, cited 130 times) The three most commonly cited articles in the FM literature in the past 10 years were: 1. The impact of patient centered care on outcomes. Stewart MA et al 2000 J Fam Pract 49(9): , cited 385 times 2. The Future of Family Medicine: A collaborative project of the Family Medicine Community. Martin JC et al 2004 Ann Fam Med 2 (Suppl. 1):S3-S32, cited 313 times 3. Motivational interviewing: A systematic review and meta-analysis. Rubak S et al (513): , cited 188 times. So, this helps define what we as a discipline have been talking about within our own journals and find important enough to be citing. This is part of what I have called our internal discussion. What then has been the impact of academic FM on medicine in general, the external discussion? It is harder to generate any data or information on this, but I would argue for the following areas: 1. The importance of considering context in the approach to patients beginning with proximal context such as family, and occupation and distal context such as neighborhood, and environment. Many disciplines outside of medicine are recognizing the importance of context as well. The discipline of family medicine comes closest of any discipline to merging or bridging the divide between the environmental-adaptive approach and the structuralist approach. 2. The importance of the subjective. Here I am referring to taking into account patient s own experiences of ill health. There has evolved a rich literature in print and in blogs of illness narratives that help inform clinicians about their patients experiences. 3. Emphasis on the humanities in medicine. Of course FM is not alone in this, but typically our departments have contributed greatly to raising the issue of a more humane approach to medical care to balance off what is an increasingly technological, instrumental approach to health care. 4. Attention to marginalized populations brought about, in part, because we practice in the community setting and are as a result more aware of these unmet needs. Family medicine faculties are often leaders in establishing and maintaining standards of equity in the university and wider community. 5. We talk, though not loudly enough, of healing, something that is largely alien within Academic Health Science Centers where curing is most often the utopian goal. 6. Related to this is a characteristic of all truly accomplished physicians that sometimes is called clinical wisdom. It is a trait that family physicians are uniquely positioned to perfect. Robertson Davies, a Canadian novelist and playwright refers to this as: that breadth of spirit which makes the difference between the first rate healer and the capable technician. [12] The philosopher, Stephen Toulmin cautions: Many of those who practice the clinical arts may set out to maintain the kind of spirit that Davies calls Wisdom, but the narrower their viewpoint and the more academic their preoccupations, the less likely they are to succeed. [13] 7. Finally, in the list of family medicine s contributions to the academy, is the patient centered clinical method which represents a significant departure from the standard clinical method. The Patient Centered Clinical Method [14] has been clearly defined and research carried out to understand it better. It has been shown that it improves health outcomes and that it can be taught. It is widely endorsed and embraced even outside FM, though frequently not well understood. I have tried to place the emergence of FM as an academic discipline within the broader field of medicine and to examine the nature of our internal and external discussion. I want to turn now to what I see as the key challenges for FM s future academic development. 1. First and foremost I believe that we in academic departments of family medicine need to devote more time to scholarly activities. In the Canadian National Physician Workforce Survey of 2010, [15] FP respondents reported that they spent 1.11 hours/week in teaching and education and only 0.68 hours/week in research. In contrast, specialists reported 2.20 and Freeman T Family Medicine s academic contributions

9 hours/week in these activities respectively, a 2-3 fold difference. The reasons for this are certainly complex, but explain the frequently observed inability of medical students to view family medicine as academically challenging. This must change. 2. We must continue to deepen our intellectual base by furthering the development of academic post-residency programs and fellowships in research. The Masters in Clinical Science in FM at Western University has graduated 86 family physicians who have taken leadership positions such as Deans of Medicine, Department Chairs, curriculum developers etc. A recently launched PhD program has attracted a great deal of interest and graduated its first student this fall. Many countries outside of North America have doctoral programs in family medicine. These programs and the graduates from them are the chief way in which we can influence the greater field of medicine. 3. No academic development in FM can take place apart from the clinical base. We must strengthen and maintain connections between clinicians and researchers. This closeness also means that further academic development will be closely intertwined with changes occurring in the practice of FM. Team based care, is becoming increasingly common and has significant implications for how family practice is carried out. 4. We must take into account the ramifications of the information explosion and digitization of information. Computer scientist Herbert Spencer tells us that as information increases, attention falls. Since the 1960 s the ability to manipulate data and information has increased by 10M times.this means that our attention relative to the amount of information has grown increasingly scarce. [16] If knowledge is taken to be the product of information and attention, one effect of the information explosion has been that knowledge has changed from something that is stored like stock in a factory (e.g. in books) to a flow (e.g. Wikipedia). This environment resists attempts to appreciate what is deep and nuanced in favor of what is fast and focused. As a discipline we need to examine what this means for the framework used in the clinical encounter. In research, the just in time approach to knowledge serves to narrow our field of vision and reduces the chance of serendipitous discoveries. What is eroded is the deep, integrative mode of knowledge, precisely the kind of activity in which a fully engaged family physician is best. In conclusion, I have tried to place FM in the wider landscape of academic medicine and provide some sense of how it has grown in its own right as an academic discipline with unique contributions to provide. As an academic discipline, it has established a firm foundation over the past 40 years. References 1. Reiser SJ. Technological medicine: the changing world of doctors and patients. Cambridge: Cambridge University Press; p Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching. Bulletin number Four (1910) 3. Osler W. The principles and practice of medicine: designed for the use of practitioners and students in medicine. New York: D. Appleton and Company; Kuhn T. The structure of scientific revolutions. International Encyclopedia of Unified Science. Vol. 2, Number 2. Chicago: The University of Chicago Press; oss L. The challenge to biomedicine. J Med Philos 1989;14: Moerman DE. Placebo effects in the treatment of ulcer disease. Medical Anthropology Quarterly 1983;14:3. 7. Rana J, Mannam A, Donnel-Fink L, et al. Longevity of the placebo effect in the therapeutic angiogenesis and laser myocardial revasculaturization trials in patients with coronary heart disease. Am J Cardiol 2005:95: Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008;5:e Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. N Engl J Med 1993;328: McWhinney I R. General practice as an academic discipline: reflections after a visit to the United States. Lancet 1966:19: Culpepper L, Becker L. Family medicine research: two decades of developing its base. In: Doherty WJ, Christianson CE, Sussman MB, editors. Family medicine: the maturing of a discipline. New York, NY: The Howarth Press; Davies R. Can a doctor be a humanist? In: The Merry Heart: Selections Toronto, ON: McClelland and Stewart; Toulmin S. Return to reason. Cambridge: Harvard University Press; Stewart M, Brown JB, Weston W, McWhinney I, McWilliam C, Freeman T. Patient-centered medicine: transforming the clinical method. 2nd ed. Oxon: Radcliffe Medical Press; National-Q18.pdf 16. Nicholson P. Information-rich and attention-poor. Globe and Mail 2009;September 9. Durum Raporu Türkiye Aile Hekimli i Dergisi Turkish Journal of Family Practice Cilt 16 Say

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